Varicose Veins

Question 1

What are varicose veins

Answer 1

Distended superficial veins >3mm diameter, usually affecting legs

Question 2

What are reticular veins

Answer 2

Dilated blood vessels in skin measuring <3mm diameter

Question 3

What is telangiectasia

Answer 3

Dilated blood vessels in skin <1mm diameter, also called spider or thread veins

Question 4

How do they develop

Answer 4

• Normally, valves prevent backflow of blood and bloods moves towards heart with contraction of leg muscles
• Valves become incompetent and blood drawn downwards by gravity and pools in veins and feet
• Perforating veins connect deep and superficial veins, when valves incompetent blood travels from deep to superficial and caused dilation of vessel, forming varicose veins

Question 5

What happens in chronic venous insufficiency

Answer 5

• Blood pools in distal veins, pressure causes vein to leak small amounts of blood into nearby tissues
• Haemoglobin breaks down to haemosiderin which is deposited around shins causing brown discolourisation
• Pooling causes inflammation, skin becoming dry and inflammed called venous eczema
• Skin and soft tissue becomes fibrotic and tight, causing lower legs to become hard and narrow called lipodermatosclerosis

Question 6

AETIOLOGY

Risk factors

Answer 6

• Increasing age
• Family history
• Female
• Pregnancy
• Obesity
• Prolonged standing (e.g., occupations involving standing for long periods)
• Deep vein thrombosis (causing damage to the valves)

Question 7

CLINICAL FEATURES

Presentation

Answer 7

• Engorged and dilated superficial veins
• Can be asymptomatic or
  
  • Heavy or dragging sensation in legs
  • Aching
  • Itching
  • Burning
  • Oedema
  • Muscle cramps
  • Restless legs
• Maybe signs of chronic venous insufficiency

Question 8

INVESTIGATIONS

Special tests

Answer 8

• Tap test
• Cough test
• Trendelenburg test
• Perthes test
• Duplex US

Question 9

INVESTIGATIONS

How is tap test performed

Answer 9

Apple pressure to saphenofemoral junction and tap distal varicose vein, feeling for thrill at junction

Thrill suggests incompetent valve

Question 10

INVESTIGATIONS

How to perform cough test

Answer 10

Apply pressure to saphenofemoral junction (SFJ) and ask patient to cough

Thrill suggests incompetent valve

Question 11

INVESTIGATIONS

How to perform trendelenburg test

Answer 11

• Patient lying down, lift affected leg to drain veins completely
• Apply tourniquet to thigh and stand patient up
• Should prevent varicose veins from reapeearing if placed distally, if it appears the incompetent valve is below level of tourniquet
• Repeat to assess location of incompetent valves

Question 12

INVESTIGATIONS

How to perform perthes test

Answer 12

• Apple tourniquet to thigh and ask patient to pump calf muscle by performing heel raises whilst stranding
• If superficial veins disapear the deep veins are functioning, increased dilation indicates problem with deep veins such as DVT

Question 13

MANAGEMENT

General principles

Answer 13

• In pregnancy resolve after delivery
• Conservative treatment
• Surgical options

Question 14

MANAGEMENT

Simple treatment measures

Answer 14

• Weight loss
• Exercise
• Keeping leg elevated when possible to help drainage
• Compression stockings (exclude arterial disease first with ankle-brachial pressure index)

Question 15

MANAGEMENT

Surgical options

Answer 15

• Endothermal ablation (inserting catheter into vein to apply radiofrequency ablation)
• Sclerotherapy (injecting vein with irritant foam to cause closure)
• Stripping (veins ligated and pulled out of leg)